apply for Membership "*" indicates required fields Step 1 of 3 – About you 0% All information given on this form will be treated in confidence within Broken Rites.Full Name* Address* Street Address Address Line 2 City County Post Code Phone Number*Alternative Phone NumberEmail* Date of Birth DD slash MM slash YYYY Year of marriage/partnership breakdown* Denomination of spouse / partner from whom you are separated / divorced* C of E, URC, Methodist etcDiocese / area where you were living at time of marriage / partnership breakdown* How did you hear of Broken Rites?* Someone who knew my circumstances told me about it Facebook Twitter Church or friend from church Church Times Other newspaper Radio or TV Other Are you in contact with your Bishop's Visitor or other support from your denomination beyond the local church?* Yes No Our membership Secretary will be in touch about admin matters. Would you like someone else to contact you now to talk about your circumstances?* By phone call By text By e-mail On Messenger Not now but maybe in future: I will inform Broken Rites when/if this is the case Would you like to join our confidential group on Facebook?* Yes No Maybe Are you willing for these details to be shared with membership reps and links within Broken Rites so they can support you?* Yes No Maybe in future after further discussion Are you willing for these details to be shared with other members in your region, for mutual support?* Yes No Maybe in future after further discussion Annual subscription First year membership is free. Thereafter, annual subscription is £15 or, in case of hardship, not less than £2. Online payment – when required – should be made to: Sort code 60-22-45 Account 72017325 (ensure your name is shown as reference) Rite Lines Our twice yearly newsletter can be received in booklet form by e-mail or post.Please indicate your preference for receiving Rite Lines:* e-mail (PDF) post Do you consent to the Broken Rites Membership Secretary retaining this information in accordance with our Privacy Policy?* YesAny questions? Contact: membership@brokenrites.org Please update us if/when any of your contact information changes, so we can keep in touch. Thank you! Δ
